A new bipartisan committee’s working group will gather on Capitol Hill throughout the coming months to find ways to improve electronic health records, according to Senate health committee chairman Lamar Alexander (R-Tenn.) and ranking member Patty Murray (D-Wash.).

The group will work to find five or six ways to “make the failed promise of electronic health records something that physicians and providers look forward to instead of something they endure,” Murray said in an announcement.

All members of the Senate health committee are invited to be a part of the working group. Staff meetings begin this week, with participation from health IT professionals, industry experts and government agencies.

The working group’s goals include the following:

Help providers improve quality of care and patient safety.

Facilitate interoperability between EHR vendors.

Empower patients to engage in their own care through access to their health data.

Protect privacy and security of health information.

The working group isn’t the only way Alexander and Murray are pushing for change when it comes to EHRs.

12/1/2014
By: Health.mil Staff
We just completed a remarkable first year in the Defense Health Agency.

In December, you will all be receiving our first Annual Report on what we have accomplished, and where we are headed in 2015. But let me give you a preview of what I consider the principal takeaways from our first year.

Unity of Effort is critical. Our successes in year 1 are directly attributable to your ability to bring people together on behalf of our broader purpose in military medicine. We put a new system of decision-making for the Military Health System (MHS) in place. And it ensured engagement at every level – the Office of the Secretary of Defense, the service secretaries, the Joint Chiefs, the service Surgeons General and all of their staffs. To some, the MHSER, the SMMAC, the MDAG, the MOG, BOG, and MPOG are an alphabet soup of bureaucracy. But not to me, and hopefully not to you. These committees are the machinery that allows us to tee up, vet and make sound decisions on the future of this vital system of care. Together.

The business of building consensus is not easy – but the payoffs are enormous. And, so for the many initiatives that we introduced this year, we succeeded when the hard work of building trust, ensuring transparency and skillful execution were sustained.

And the inverse is also true, when unity of effort was lacking, when the processes became slow or bogged down – sometimes on substantive policy issues, sometimes on minutiae, and sometimes on simple misunderstanding – we fell short of our goals. But, if we had nothing but successes this year, I think it would be a sign that we were not challenging ourselves enough. Perseverance matters. We will pick it up in 2015.

Success is not only measured in dollars saved. I am as pleased as anyone that we saved $250 million in 2014, which was $250 million more than we projected! This was supposed to be a building year, creating the infrastructure and hiring staff. But through aggressive action by leaders at all levels, we also provided the department and the taxpayer with a return on investment. Yet, equally important to saving dollars is the long-term work of creating common clinical and business processes.

Let me give you one example of an area where no money has yet been saved, but tremendous progress has been made: creating a common cost accounting structure for the MHS. This has been “behind the scenes” work by an often unheralded team of budget and financial management experts. They are positioning the MHS for the long-game.

In the coming years, we will look back at the work of 2014 – across all of our domains – and we will recognize this was the beginning of a process that genuinely allows us to compare performance in a meaningful way across the system of care. Not just counting dollars and cents, but utilization, outcomes, quality, safety and access to care. Not every success has a price tag on it, but they are all valued.

2014 was a down payment on a bigger promise. It has been a transformational year. At the same time that we stood up the DHA, which required a tremendous amount of energy and intellect in its own right, we have also played an indispensable role in the Secretary of Defense’s “Review of the Military Health System” and in implementing the action plan that followed it. We have an important role to play – in creating, maintaining and communicating a Performance Management System as well as a broad mandate for ensuring greater transparency to the public.

Now, add in the deployment of thousands of service members to West Africa in support of the larger federal response to the Ebola outbreak, along with the deployment of service members to Iraq to confront the threats from ISIS, and you have a sense of why having a “Medically Ready Force…Ready Medical Force” is more than a mere slogan; it is a perpetual promise in our combat support agency role.

In such a world, our customers – the services and the combatant commanders – need a system that ensures their medical logistics needs are met. They need medical facilities that are designed, built and sustained for 21st century medicine. They need a pharmacy system that can deliver vaccines, therapeutics and other medicines that prevent disease when possible, and treat disease when needed, which is often immediately. They need a health system in which private sector providers complement our direct care system and reach every corner of the globe where our service members and families live and work. They expect the care that we provide in Afghanistan, Iraq, Liberia, South Korea or the South Pacific to be captured, shared and available worldwide to our medical teams through a functioning Electronic Health Record. They need a global public health system that monitors the environment and disease threats anywhere in the word. They demand a medical research and development system that never stops the search for better ways of addressing the myriad of threats and disease and injuries we face in this unique line of business. They need us to educate and train thousands of new recruits and experienced professionals. They need a procurement system that can respond in a timely manner with high quality products and services. And they need us to properly budget, oversee and account for all of these things. And they need leading, joint institutions for health care delivery – and they are right here in the National Capital Region.

And they need the DHA.

And we have a deep moral and personal obligation to ensure that their needs are met.

I know that many of you were double and triple-tasked to manage the avalanche of requests for policy reviews, data calls, and briefings. But it all had a purpose. In Dr. Woodson’s words, we are building a better, stronger, more relevant MHS. I can see the concepts that were just words a year ago beginning to take root. This has been an extraordinary year of progress. And, yet, our work has just begun. So, let’s keep our sleeves rolled-up and let’s keep our unity of effort focus … we’re burning daylight as we speak!

By Anna McCollister-Slipp
Anna McCollister-Slipp is co-founder of Galileo Analytics, a visual data exploration and advanced data analytics company focused on democratizing access to and understanding of complex health data. She is a member of the judging panel for the $10M Qualcomm Tricorder XPRIZE.

The digital health revolution has failed… so far. The industry that has grown up around it — to cheer it on and promote its potential — is thriving. But while those who organize conferences, found coalitions and work as consultants gain acclaim, write books and give TED talks, patients and physicians wait for the promise of the digital health revolution to become a reality.

We’re tired of waiting.

For those of us with chronic disease, a digital health revolution is the best chance we have. We need it to succeed. We’re desperate for innovation that works. We have experienced tremendous developments and intuitively grasp the potential, but when we peruse the app store and download a few, their usefulness rates as “meh” at best.

We stare longingly at Apple’s new Health app on our iPhones, only to discover it can’t access our data. So back we go to tracking our information on multi-page printouts, or Post-It notes, or in our heads. We receive our lab results via fax, phone, in the mail, or if our doctors are willing to take the risk — via email. We see news stories detailing the government’s investment in the digitization of health and are awed that so much money and discussion can produce such limited results.

In the past five years, we have committed $33 billion taxpayer dollars to digitize our nation’s health care data. The need was unquestionable, and the potential gains are tremendous. However, the system that has emerged has essentially replicated — in digital form — the acute care-focused health system that has been failing us for decades as we grapple with the growth in chronic disease.

Few of the hospitals receiving government incentive payments to install digital health tools are willing or able to incorporate the data generated by a patient’s personal medical device into that patient’s electronic health records, even for data-intensive diseases like diabetes.

At the same time, according to StartUp Health, since 2010, we have invested nearly $13 billion in mobile and digital health ventures aimed at building apps to promote health. But those who could most benefit from these new tools — those with chronic disease — aren’t using them. In fact, most of the “health” apps available to date are for those who are healthy.

A 2013 IMS Institute study showed that of the nearly 44,000 “health” apps in the app store, less than half were legitimately related to health. Of those that were, most were focused on prevention or wellness, with fewer than 2,000 aimed at individuals with a diagnosis. And of those that were downloaded, few were used regularly. A separate study by Research2Guidance, which looked at diabetes apps, was even more damning. Despite numerous surveys citing diabetes as the ultimate example of a disease that will benefit from mobile health, only 1.2 percent of diabetes patients with smart phones use digital health apps because of the need to manually input data.

It’s not that we aren’t tracking our information — we are. A recent Pew study shows that while most Americans living with chronic illness track certain health metrics related to their disease, 41 percent use a pencil and paper, while 43 percent say they track of things “in their head.” (Both of which tend to work better than most health apps available today.)

Life with Digital Dysfunction

So how does this all play out? Let’s use me as an example: Like many patients with Type 1 Diabetes, I have a number of co-morbid diseases, complications and diagnoses. Each day, I take 15 medications. I use eight medical devices (four that are prescription, four that are not). Two devices are literally attached to my body 24/7, and the rest are never far from of reach. In 2013, I saw 13 different physicians and had a total of 63 doctor’s appointments. I had multiple blood draws tracking more than 100 lab values — all the while being sure to eat right, get plenty of sleep, and do several forms of exercise.

How much of this did I manage digitally? Not much. I’m swimming in data that could be helpful, but that data is mostly inaccessible. All of my devices generate data in one form or another: my continuous glucose monitor generates glucose levels every five minutes, 24/7. My insulin pump records the dosage of my insulin and stores the data for months. My blood glucose meter stores the glucose measures I take between five to 10 times a day, and my fitness tracker, digital scale, heart rate monitor and blood pressure cuff all generate electronic, structured data that could be easily combined into a single timeline to illuminate important patterns that could help me manage my health. It could be helpful, but it isn’t. Accessing the data stores is clumsy at best. I can’t even download my CGM data to my Apple computer — the software only works on Windows. Even when I can access the data, the process takes hours, and combining it manually for most people is impossible.

And it isn’t just about the devices. I receive most of my medical care at a large, academic health institution located less than five miles from where our nation’s health IT policy is generated, but I still can’t access my electronic health record online or communicate with my physicians electronically. And, the hospital’s IT department refuses to give my endocrinologist access to the free software required to download my CGM data on his computer.

Despite the fact that the major diagnostic labs in the country have been sharing data electronically with physicians for years, the only way I can get my lab results is through emails from my physicians who choose to risk a HIPAA violation to give me the information I need to manage my health. None of my physicians use electronic scheduling, despite the fact that secure online scheduling tools have been available for years. And only one permits me to request prescription refills electronically.

Now here’s the good news: All of this is fixable. The technology part is easy. We know how to make this work, but we lack the societal will to make it happen. The government can do much to push the system along, but device manufacturers, technology companies and hospitals need to do the rest. We spend billions to find breakthrough cures for the future, yet fail to follow through on the “easy” wins that can take us so far today.

Curing disease is difficult. Making data streams accessible and interoperable is not.

A pedestrian wears a surgical mask as he crosses the street in front of Texas Health Presbyterian Hospital.

Credit Nathan Hunsinger/The Dallas Morning News

Hard Cases

Dr. Abigail Zuger on the everyday ethical issues doctors face.

Will history someday show that the electronic medical record almost did the great state of Texas in?

We do not really know whether dysfunctional software contributed to last month’s debacle in a Dallas emergency room, when some medical mind failed to connect the dots between an African man and a viral syndrome and sent a patient with deadly Ebola back into the community. Even scarier than that mistake, though, is the certainty that similar ones lie in wait for all of us who cope with medical information stored in digital piles grown so gigantic, unwieldy and unreadable that sometimes we wind up working with no information at all.

We are in the middle of a simmering crisis in medical data management. Like computer servers everywhere, hospital servers store great masses of trivia mixed with valuable information and gross misinformation, all cut and pasted and endlessly reiterated. Even the best software is no match for the accumulation. When we need facts, we swoop over the surface like sea gulls over landfill, peck out what we can, and flap on. There is no time to dig and, even worse, no time to do what we were trained to do — slow down, go to the source, and start from the beginning.

On the hospital wards, mixed messages abound. A couple of months ago, I was on the receiving end of a furious, expletive-laden outburst from one sick patient, the printable fraction of which ran, “Can’t you people read?”

This man had by then recounted the long story of his bad leg to three separate teams of doctors and nurses. I was the 14th interrogator by my count, and despite my standard opening gambit (“I know you’ve been over this before”) I was the one to flip his switch: The patient ordered me and my team out of his room and pulled the covers over his head.

Who can blame him for assuming that in this day and age, once told, his story needed only to be retweeted. But medical care requires dialogue. Although we plucked some information from the glut of words in his chart and cobbled together a plan, we didn’t do him justice, not by a long shot.

The fact is that even if all the redundant clinical information sitting on hospital servers everywhere were error-free, and even if excellent software made it all reasonably accessible, doctors and nurses still shouldn’t be spending their time reading.

The first thing medical students learn is the value of a full history taken directly from the patient. The process takes them hours. Experience whittles that time down by a bit, but it always remains a substantial chunk that some feel is best devoted to more lucrative activities.

Enter various efficiency-promoting endeavors. One of the most durable has been the multipage health questionnaire for patients to complete on a clipboard before most outpatient visits. Why should the doctor expensively scribble down information when the patient can do a little free secretarial work instead?

Alas, beware the doctor who does not review that questionnaire with you very carefully, taking an active interest in every little check mark. It turns out that the pathway into the medical brain, like most brains, is far more reliable when it runs from the hand than from the eye. Force the doctor to take notes, and the doctor will usually remember. Ask the doctor to read, and the doctor will scan, skip, elide, omit and often forget.

The same problem dogs other efforts to reduce the doctor’s mundane history-taking responsibilities. For instance: Why not leave it to the nursing staff to ask all those dull questions about smoking, drinking, social activities and recent travel? They will write it all down. The doctors will review.

And then the next thing you know, that unimportant background information explodes all over the nightly news, because the doctors failed to review, or failed to remember what they reviewed, and key travel details simmered unnoticed in the bowels of some user-unfriendly electronic medical record.

Over and over again we are forced to admire the old traditions. As we tell the students, it’s not that complicated. You say hello, you sit down, and you have a conversation.

A few months after our expletive-spewing patient got better and went home, our team went to see a more cooperative young man admitted to the hospital with a fever. This one had gotten sick after a camping trip in California, and the words “camping” and “California” were repeated over and over again in his chart, escalating into the general conviction that he had come down with a serious fungal infection that can be acquired from the soil in some parts of Southern California.

If this patient had refused to talk to us, we might have been tempted to treat him for that infection, which would have been a big mistake. Fortunately, he politely led us through his entire hike, which proved to have skirted the habitat of this fungus by hundreds of miles. We could tell his other doctors to stop focusing on his travels and pay attention to his heart murmur instead, the real clue to his problems.

Like good police work, good medicine depends on deliberate, inefficient, plodding, expensive repetition. No system of data management will ever replace it.

WASHINGTON, Oct. 1, 2014 – Defense Secretary Chuck Hagel has ordered improvements in the Military Health System, saying a 90-day review of the system that found it comparable in access, quality and safety to care offered on average in the private sector is not good enough for service personnel and their families.

“We have the finest military in the world,” Hagel said during a briefing today on results of the review. “Our men and women in uniform and their families deserve the finest health care in the world.”

In May, the defense secretary ordered a comprehensive review of the Military Health System, or MHS, to be led by Deputy Defense Secretary Bob Work.

It sought to assess whether access to medical care in the MHS met defined standards, whether the quality of health care in the MHS met or exceeded defined benchmarks, and whether the MHS had created a culture of safety with effective processes for ensuring safe and reliable care of beneficiaries.

Pockets of excellence

“The review found pockets of excellence, significant excellence which we’re very proud of,” Hagel said, “and extraordinary doctors, nurses and staff who are deeply dedicated to the patients they serve.”

But he said, “It also found gaps, however, and facilities that must improve.”

The bottom-line, the secretary said, “is that the military health care system provides health care that is comparable in access, quality and safety to average private-sector health care. But we cannot accept average when it comes to caring for our men and women in uniform and their families. We can do better; we all agree that we can do better.”

Hagel said he’s directing the department to take steps to ensure that the entire military health care system is not just an average system but a leading one.

First steps

“These are first steps but they will help our hospitals and clinics foster a stronger culture of safety, quality and accountability,” he added, “a culture that must become second nature to all who execute DoD’s critical health care system and our mission.”

Hagel has also directed all health care facilities identified as outliers in categories of access, quality and safety to provide action plans for improvement within 45 days.

The secretary has also directed Dr. Jonathan Woodson, assistant secretary of defense for health affairs, and the military services surgeons general to ensure that the department has unified standards for purchased and direct care.

Hagel also ordered them to establish a mechanism by which patients and concerned stakeholders can provide ongoing input.

System-wide performance management

“I’m also directing the department’s health care leadership to establish a system-wide performance management system that will help scrutinize lapses and monitor progress,” the secretary added. “And to enhance transparency I’m requiring that all … data on our health care system be made publicly available.”

By the end of the year, Hagel said, DoD will have a detailed implementation plan to ensure that MHS becomes the top-performing system those in the department expect it to be and want it to be.

Work said the Defense Department has no higher priority than its men and women.

Sacred compact

“They are the true secret weapon that the United States has … and they deserve the finest health care that we can possibly provide. It’s a critical part of the sacred compact that we have made … and when the secretary asked me to do this I was actually quite excited.”

Work said he was born into a Marine family and experienced the MHS in the continental United States and oversea, as a Marine, through NROTC, and later as a Marine with a family — wife who is a former Army nurse and a daughter.

“I feel that I have a lot of firsthand experience on what this system provides. I know it pretty well and I share the secretary’s commitment on getting it right,” he said.

Work said the department was happy to hear that its health care system is comparable on average with the national civilian health care system.

A leading organization

“But as the secretary said, he does not expect us to be average. He wants us to be a leading organization and he has tasked us to do so,” Work added and said that after meeting with veterans’ service organizations and other interested groups, the department now has a good idea about areas where improvements are needed.

“This will be the start of a process in which we all commit ourselves to becoming a leading organization.”

An amputee wearing the DARPA-funded “Modular Prosthetic Limb,” shakes hands with a fellow attendee at the Federal Advanced Amputation Skills Training symposium in Arlington, Va., in July 2014. Photo by Randy McCracken.

Fred Downs is a bit of an anomaly. An infantry Veteran of Vietnam, he’s more Andy Griffith than Robocop. It’s easier to imagine him telling the grandkids a story than demonstrating space-age technology in front of a room full of clinicians and researchers from VA and the Department of Defense. But that’s just what he was doing in early July during a three-day symposium at the VHA National Conference Center in Arlington, Va. The event, titled “Federal Advanced Amputation Skills Training (FAAST),” was sponsored by the VHA Employee Education System, the VHA Office of Rehabilitation and Prosthetic Services, and the Department of Defense.

For more on the Modular Prosthetic Limb see the article from VA Research Communications.